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Mindfulness-Based Stress Reduction (MBSR) Tools

Re-discovering your nature.

MBSR Tools

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Questionnaire

Thank you for filling this out at the start of the program. I realize the personal nature of these questions. Please be assured that completed forms are kept in strict confidence.

Thank you for your response. ✨

Name(required)

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Email(required)

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Student ID Number (all identifying info will be removed later)

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What is your main reason for participating in MBSR?

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What do you care about most?

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What gives you the most pleasure in your life?

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What are your greatest worries?

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Please list three personal goals you have for taking the MBSR Program

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Are you currently engaged in psychotherapy?

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If not, have you been in therapy during the last three years?

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Any Psychological hospitalizations? If so, when?

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During the last MONTH have you…

Considered Suicide?

Yes

No

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Sought psychiatric help?

Yes

No

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Had thoughts of death or dying?

Yes

No

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Had urges to beat, injure, or harm someone?

Yes

No

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Had urges to smash or break things?

Yes

No

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Had spells of terror or panic?

Yes

No

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